Public image of nursing in modern society: An evolving concept analysis

Abstract Aims This study aimed to analyse the evolution of the public image of nursing in the context of the constantly developing nursing profession. Design The Rodger's evolving concept analysis was applied. Methods PubMed, CINAHL, Web of Science, Scopus, and ProQuest databases were searched for articles published between 1 January 2001, and 30 April 2022, using the search terms; “NURS * AND image”. The selected literature was screened using Rodgers' evolutionary method to explore the attributes, antecedents and consequences of the concept. Results The defining attributes were identified as nursing (nursing as the collective object), public (public as the collective subject) and information (the medium of interaction between the collective subject and the collective object). Nursing elements were classified into intrinsic elements (professional spirit, professional knowledge and professional skills) and extrinsic (appearance, language and behaviour) elements. Public elements were further subcategorized into public categories (internal organizational public and external organizational public) and public perceptions (cognition, emotion and behavioural intention). The information elements are mainly classified as information generation, dissemination, identification, processing and judgement. The antecedents and consequences of the public perception of nursing were also identified. Conclusions The public image of nursing is dynamic and has evolved over time. Its dynamism and malleability imply that the traditional public image of nursing can be improved through targeted interventions in nursing practice, management and education. Implications for the Profession Identifying the antecedents and consequences associated with the public image of nursing will help the healthcare organizations adopt effective strategies to alleviate the shortage of the nursing workforce and promote the development of the nursing profession. No Patient or Public Contribution.


| INTRODUC TI ON
The public image of nursing has been a topic of concern because it is not only related to the shortage of the nursing workforce (Ndirangu et al., 2021;Somers et al., 2010;Squires et al., 2019), but also affects the development of nursing profession (López-Verdugo et al., 2021;van der Cingel & Brouwer, 2021).Traditional stereotypes are still dominant in the media and the public, for example, nursing is often portrayed in the media as feminine and caring (Elmorshedy et al., 2020;Stanley, 2008), but these images are inaccurate and can have a negative impact on the recruitment of nurses (Morris-Thompson et al., 2011).Such biases, they may discourage potential students, particularly men, from pursuing a career in nursing (Morris-Thompson et al., 2011).Additionally, the public tends to perceive nurses as being subordinate to physicians (Price et al., 2013), as nurses do not require higher levels of education (Hadid & Khatib, 2015;Hoeve et al., 2014) and advanced nursing techniques (Hadid & Khatib, 2015).These perceptions may eventually reduce a decline in nurses' self-esteem and professional identity (Hoeve et al., 2014) and increase their willingness to leave the profession (Elmorshedy et al., 2020;Takase et al., 2006).
There are ongoing efforts to address the issue of professional image in the nursing industry.Consequently, multiple strategies have been developed to improve public perceptions about the nursing profession (Auker, 2004;Emeghebo, 2006), and some of the typical examples have been reported in the literature are as follows: 'Truth in Nursing', is a non-profit organization dedicated to raising public awareness of the role of nurses (Geller & Summers, 2014).It conducts educational training programmes for nurses to improve their professional competence (Toren et al., 2011), and organises hospital visits for senior high school students as educational summer camps to elicit their interest in nursing (Drenkard et al., 2002;Gomez & Brostoff, 2018).The Johns Hopkins School of Nursing in the United States produces and disseminates nursing advocacy videos through social media to communicate the goals and scope of nursing work (Kress et al., 2018).As a result, there has been an increase in people's positive attitudes towards nursing (Ali et al., 2021;Donelan et al., 2008;Kalisch et al., 2007).A survey by Kalisch et al. (2007) on the media image of nurses showed that approximately 70% of internet sites considered nurses to be intelligent and educated, and 60% considered nurses to be respected, competent, and trustworthy.A questionnaire survey in Pakistan also revealed that 70% of the participants believed that nursing is a respectable profession and 88.5% of the participants believed that the nursing profession has a good future (Ali et al., 2021).Although an increasing number of people appreciate nursing, it is still not viewed as an attractive career (Ali et al., 2021;Meiring & van Wyk, 2013;Ndirangu et al., 2021), and the shortage of the nursing workforce has been largely remained unchanged (Ndirangu et al., 2021), possibly due to the public's perceptions and opinions regarding nursing (Ndirangu et al., 2021).Professions that serve the public must carefully consider how people perceive and evaluate them because public perception not only affects the service delivery of professionals (López-Verdugo et al., 2021;Valiee et al., 2020), but also influences their recognition by the state, professional organizations and the public.Therefore, establishing a positive public image for nursing is an urgent issue that must be addressed to create an empowered nursing workforce.
Establishing a positive public image of nursing primarily requires a clear understanding of the concept of public image.
Current definitions of this concept are diverse and are based on different perspectives.Milisen et al. (2010) state that the public image of nursing constitutes a collection of ideas, principles, perceptions, expectations, and experiences of people outside the nursing profession, especially the recipients of nursing services.Squires et al. (2019) define the public image of nursing as the perception of the entire nursing profession by 'the public', which includes people interacting with nurses.An extensive review of the literature revealed that the current understanding of "public" is vague and confusing.Valiee et al.'s (2020) study interpret the public as a non-nursing group.Although this classification reveals the exclusivity of the public image, it is general and ignores the different views and assessments of individuals who interact closely with nurses.Adopting this definition may lead to obstacles in survey research, targeted organization assessment, and the formulation of targeted intervention strategies for different categories of the public.In some studies, nursing students are not considered a part of the nursing community (Ward, 2006), however, in practice, their behaviour indirectly affects people's views about the nursing profession (De gagne et al., 2019).Therefore, a clear definition of the public and different nursing groups is warranted through concept analysis.
However, the public's perceptions of nursing frequently fail to match the reality of the profession.In addition, empathy and willingness to make sacrifices are emphasized as the main characteristics of nurses when proclaiming a nursing profession.Thus, interventions designed to increase knowledge of nursing characteristics can enhance the public's understanding of the nursing profession Ward (2006).adoptedRodgers' evolutionary method to analyse the attributes of the image of nursing and obtained six components: care, attitude, knowledge, behaviour, autonomy, and uniformity.
However, the nursing profession has evolved rapidly since the be- there is a lack of understanding of the characteristics and attributes of the concept of nursing image from the perceptive of public perception.
Studies have demonstrated the high social awareness and reputation of nursing during public health emergencies and natural disaster events (Donelan et al., 2008;Hall et al., 2003;van der Cingel & Brouwer, 2021).Currently, nurses worldwide are contributing significantly in the response to COVID-19 pandemic.It is necessary to clarify the connotations of the nursing public image through concept analysis and identify the influencing factors for a better understanding of the nursing image.

| Aims
This study aimed to analyse the evolution of the public image of nursing in the context of a constantly developing nursing profession.

| Rodger's method
Given that the public image of nursing changes over time with the development of 调the nursing profession and the changes in the healthcare system, Rogers' evolutionary method was adopted in this study to clarify the concept of public image of nursing and its current usage.The process of delineating the attributes, antecedents, and consequences of concepts is a fundamental aspect of Rogers' analytical methodology (Rodgers & Knafl, 2000).Defining attributes, which refer to the characteristics, elements, or components of a concept, enhances comprehension of the concept and differentiates it from other similar concepts.Antecedents are traits that precede or lead to a conceptual events or experiences.The outcomes are the results of applying the concept in a real-life situation (Li et al., 2018).
The study included the following systematic steps: (1) the public image of nursing was determined as a concept to be analysed; (2) key databases were selected and a retrieval strategy was defined through pre-retrieval; (3) conceptual attributes were analysed; (4) antecedents and consequences were analysed; (5) model cases that fit the concept were provided (if needed), and (6) hypotheses were verified and their applications to promote the evolution of the concept were examined (Rodgers & Knafl, 2000).

| Data source
Five databases PubMed, CINAHL, Web of Science, Scopus, and ProQuest were searched.Initially, we comprehensively explored the scope of the study regarding the nursing image using the terms "nurs*" and "image" in the titles/abstracts/subject of the studies published from 1 January 2001, to 30 April 2022.The search strategy for each database is presented in Appendix 1.
Journals articles, books and dissertations published in English that describe the attributes or, antecedents, and consequences of the public image of nursing were included.
The exclusion criteria were conference papers, comments, letters, interviews, news, viewpoints, book reviews, articles not available as full-text publications and articles only mentioning the study terms without an explanation.
The literature review process included the following five phases: (1) Original publications were searched in the electronic databases using the established search strategies and imported into Endnote7.0for further appraisal and management.(2)The title, abstract, keywords, and subject of each publication were reviewed, and preliminary screening was conducted according to the inclusion and exclusion criteria.(3) Full texts of the publications were reviewed for evaluation.(4) Full texts were analysed more deeply to identify core information and for detailed evaluation.( 5) Reference lists of all included studies were scanned to identify additionally potentially relevant studies.A flowchart of the literature screening process is shown in Figure 1.

| Data analysis
After the initial review of the included articles, we coded the key information.Themes were then identified using Roger's method.
The extracted data were placed in an Excel sheet and a thematic approach was conducted to categorize antecedents, attributes, and consequences of the public image of nursing.The two reviewers conducted in-depth analyses and discussions to determine the conceptual categories and their hierarchical structures.

| RE SULTS
A total of 54 publications were included in this study, including 50 journal articles, 3 dissertations and 1 book.

| Identifying the public image of nursing
The first study of the public image of nursing was conducted by the American Nurses Association in 1940 (Simmons, 1962).Research in this area has focused primarily on three aspects.The first was to directly survey the image of nursing as perceived by the public, including citizens, physicians, and other health professionals such as children, middle school students, high school students, medical college students, career counsellors and tutors (Hadid & Khatib, 2015;King et al., 2007;Marcinowicz et al., 2009;Meiring & van Wyk, 2013;Mert et al., 2020;Morris-Thompson et al., 2011;Neilson & McNally, 2013;Williams et al., 2018;Williams & Dickstein-Fischer, 2019).The second aspect was to indirectly understand the public's view of nursing based on media portrayal of the image of nursing (Chapman, 1977;Emeghebo, 2006).Kalisch, an American scholar, performed a series of extensive studies on nursing image representation in the media since the 1980s.These studies analysed the gender role/performance of nurses in mass media (TV, books and movies) and identified four stereotypes of nurses in different time periods: angel, handmaiden, battleaxe and sexy (Kalisch & Kalisch, 1982a, 1982b, 1982c).Subsequently, many researchers analysed nursing images in media advertisements, networks and social media (Cohen & Bartholomew, 2008;Kalisch et al., 2007;Kelly et al., 2012;Koo & Lin, 2016;Şahan et al., 2021).The third aspect was nurses' and nursing students' perceptions of nursing, which was explored by examining the relationship between the variables related to nurses' work (Karanikola et al., 2011;Rahman & Shousha, 2013;Rubbi et al., 2019;Weaver et al., 2013), such as professional identity, job performance, job satisfaction, and turnover intention (Emeghebo, 2006;Takase et al., 2002;Takase et al., 2006).
Overall, the concept of nursing public image has not been adequately elaborated in the literature.However, consistently across publications, this concept has been defined as a collection of perceptions, principles, expectations and experiences of care by people outside the nursing profession, particularly the recipients of nursing services (Milisen et al., 2010).This concept highlights that public perception of nursing is a psychological process that requires a comprehensive judgement of nursing impressions according to personal experience, values, and expectations.

| Concept analysis
The antecedents, attributes and consequences of the public image of nursing were identified using thematic analysis of the included publications.The details of each study are listed in Table 1. Figure 2 depicts the conceptual framework of the public image of nursing.

| Defining attributes
Based on the analysis of the original concept of nursing public image and descriptions in the literature, nursing public image was found to have three elements: nursing (nursing as the collective object), public (public as the collective subject) and information (medium of interaction between the collective subject and the collective object).
Initially, the public viewed the nursing profession as the object of their understanding, but through direct and indirect interactions with nursing and information medium, they formed a new impressions, views and perceptions of nursing.

| Nursing (nursing as the collective object)
In general, nurses refer to a professional group of individual nurses who are legally engaged in nursing work, either presently or in the future.Nursing is considered a collective object of public perception, objective reality, and the source of public perception.It builds and provides the image of nursing.It comprises both intrinsic and extrinsic elements.
The nursing professional spirit dimension comprises values, professional ethics, beliefs and attitudes that are considered important in the profession (Godsey et al., 2020;van der Cingel & Brouwer, 2021).It is a professional code for guiding and regulating nurses in nursing practice and its most important connotation reflects the key attributes of nursing.'care', 'compassion', 'morality', 'honesty,' 'respect' and 'autonomy' are all important nursing characteristics for both nurses and the public (Afshar et al., 2020;Cao et al., 2022;Emeghebo, 2006;Glerean et al., 2017;Morris-Thompson et al., 2011;Murphy et al., 2009;Thomas et al., 2010;Valiee et al., 2020;Varaei et al., 2012;Ward, 2006;Wocial et al., 2014).In practice, the formation of the nursing image is inseparable from the ideals and values in practice (Fletcher, 2007).The integration of professional spirit into nursing work can guide nurses to face and deal with complex value oriented problems in the clinical environment and influence nurses to fulfil their professional roles and responsibilities to improve the quality of care delivered to patients (López-Verdugo et al., 2021).
Professional knowledge means that nursing staff must have a complete set of specialised knowledge necessary to deliver quality nursing services, including theoretical, practical and clinical knowledge (Rodríguez-Pérez et al., 2022;Thomas et al., 2010).Professional knowledge encapsulates the professional attributes and important characteristics of nursing that are essential for the construction of professional identity and nursing image (Emeghebo, 2006;Rodríguez-Pérez et al., 2022;Ward, 2006).Afshar et al. (2020) believe that specialisation is at the core of the nursing profession.In highly specialised fields, nurses can apply their extensive theoretical and practical knowledge to provide precise clinical judgement and professional decision-making for the timely satisfaction of patient needs and greatly improve the quality of care provided and professional autonomy (Karanikola et al., 2011;Fealy, 2004).
Professional skills include technical, intellectual, cognitive, organizational and communication (Milisen et al., 2010), and interpersonal skills, and other skill sets involved in nursing practice that are widely used in the process of serving patients (Thomas et al., 2010).Some studies have suggested that professional skills are the most valuable characteristics of nursing effectiveness and a prerequisite for nursing practice (Rodríguez-Pérez et al., 2022;Valiee et al., 2020).Tzeng (2006) found that professional skills build positive professional images.Hadid and Khatib (2015)   The extrinsic elements of nursing are the explicit parts perceived by the public through the personal sensory system.Three extrinsic dimensions were identified: appearance, language and behaviour.
Appearance includes the look, dress, posture and movements of nurses.It is a form of nonverbal communication that people use to form judgements and behavioural responses.When interactions occur between two people, they form perceptions of each other's roles in relationships and society based on their appearance (Thomas et al., 2010).Studies have shown that the appearance of nurses is an important predictor of the nursing public image (Albert et al., 2008;Apaydin Cirik et al., 2022;López-Verdugo et al., 2021;Squires et al., 2019).The professional appearance portrayed by nurses' uniforms embody the role recognition and competency characteristics that convey a professional image of nursing to patients (Wocial et al., 2018;Thomas et al., 2010;Ward, 2006).Historically, white uniforms and dovetail caps worn by nurses represented a classic angelic image (Skorupski & Rea, 2006).Uniform-style design has remained neutral, with jackets and pants becoming the standard design, and more attention now shifting to comfort and functionality in the late 1990s (Daigle, 2018;Thomas et al., 2010).When nurses remove their hats and wear stethoscopes around their necks, they convey a professional image to the public (Skorupski & Rea, 2006).
Studies have shown that the colour and cleanliness of uniforms can affect patients' perceptions of the nursing profession.In addition, Thomas et al. (2010) have reported that nurses' inappropriate professional appearance such as tattoos and piercing of the lips and nose, can lead to patients' perceptions that nurses lack off care, knowledge and skills, reducing public trust in nurses.
Language is also an element that influences the perception of nursing (Emeghebo, 2006).Nursing practitioners in all medical institutions must treat patients with respect and compassion.The words 'please' and 'thank you' should be routinely used in practice, as respecting and appreciating patients can contribute to improvement in overall health (Appiah et al., 2020).
Nurses spend most of their shift hours caring for and interacting with patients (Maliheh et al., 2020), especially in emergency environments, which profoundly affects their perceptions of nursing (Godsey et al., 2020).Consequently, messages conveyed through their actions determine the profession's current public image (Girvin et al., 2016;Maliheh et al., 2020).According to a survey conducted by De gagne et al. ( 2019), cyber-incivility behaviours by nurses and nursing students on Twitter, such as blasphemy, drunkenness, and racial discrimination, are more visible to the public and may tarnish the image of the profession and violate the code of ethics.

| Public (public as the collective subject)
The public functions as a collective subject shaping the perception of nursing and serves as the entity responsible for recognising and appraising the nursing profession.This entity may manifest as an individual, a group, or an organization, intricately linked to, engaging with and influencing on the nursing community.
Based on the level of interaction between the public and the nursing group, the public can be divided into internal organizational public and external organizational public.The internal organizational public refers to nurses' peers (physicians, hospital administrators, health technicians, public health officials and health professions students), patients, and their families (Girvin et al., 2016;Morris-Thompson et al., 2011;Valiee et al., 2020;Varaei et al., 2012).This kind of public has a more intuitive and accurate perception of the behaviour of nursing staff, as they interact frequently with them in both work and life.The external organizational public includes the general public and media.This kind of public has little or no direct interaction with the nursing staff and forms their perception of the nursing group indirectly through other ways, such as mass media (Fletcher, 2007;Girvin et al., 2016;Morris-Thompson et al., 2011;Squires et al., 2019;Valiee et al., 2020).By combining public relations and literature descriptions, we considered mass media to have a special kind of public influence on people's image of nursing.

F I G U R E 2
The conceptual framework of public image of nursing.
Cognition refers to the knowledge and beliefs shared by the public regarding nursing and its associated information, and it serves as the foundation for the public's perception of nursing.Multiple studies have shown that members of the public still maintain traditional stereotypes about nursing (Emeghebo, 2006;Hoeve et al., 2014;van der Cingel & Brouwer, 2021), with ambiguous public images of nursing, and display a lack of awareness of nursing functions, activities and roles (Emeghebo, 2006;Foà et al., 2021;Godsey et al., 2020;Hadid & Khatib, 2015;Kalisch et al., 2007;Roshangar et al., 2021).
Emotion is a type of emotional response to nursing that represents  et al., 2008).According to a survey on public opinions of nursing in the United States, nursing is considered a highly respected profession, and the public tends to endorse nursing as a career choice for students (Donelan et al., 2008).In contrast, negative emotions frequently result in poor behavioural intentions (Sahakyan et al., 2020) and mistrust in nurses' competence in carrying out nursing activities (Sahakyan et al., 2020).When the public holds negative attitudes towards nursing, they are sceptical of nurses' ability to care for patients (Sahakyan et al., 2020).
The public's perception of nursing relies heavily on the elements of cognition, emotion, and behavioural purposes.Cognitive information has a direct impact on the public's affective judgement, which in turn affects their behavioural choices.Public perception not only helps to depict the development process of the nursing public image, but also represents the outcomes of that image.

| Information (medium of interaction between the collective subject and the collective object)
Research shows that the information obtained by patients from their interaction with nurses and the portrayal of nurses in the media influences people's views on nursing (Ali et al., 2021;Donelan et al., 2008;Meiring & van Wyk, 2013;Şahan et al., 2021;Ward, 2006).This information exchange between nurses and the public forms a circulation system through which a public image of nursing is developed (Auker, 2004;Hallam, 1998).From the perspective of image generation, we conclude that subject-object interaction is realised through information generation, dissemination, identification, processing and judgement.
Information generation reflects the objective basis for how nurses shape information.Information generation in nursing is a precondition for understanding nursing and the public impressions and views about it (Cabaniss, 2011;Cao et al., 2022;Gill & Baker, 2021;Wocial et al., 2018).Information dissemination is an important channel through which nursing professionals can connect with the public.Both information sources and media play important roles in the process of dissemination (Apaydin Cirik et al., 2022;Maliheh et al., 2020;Meiring & van Wyk, 2013;Morris-Thompson et al., 2011;Rubbi et al., 2017;Ward, 2006;Weaver et al., 2014).
We propose that mass media can be both the sender of information content and the medium of information dissemination.The mediatransmitted content can significantly affect the public's assessment of nursing information (Foà et al., 2021).Several complex psychological processes, such as information identification, processing and value judgement, mediate the interaction between the public and the nursing profession, and, hence, influence the formation of a public view of nursing or nurses (Rubbi et al., 2017;Squires et al., 2019;van der Cingel & Brouwer, 2021).Information identification, processing, and evaluation reflect the public's subjective initiative and creativity of the public.Therefore, the public image of nursing is built through a process of direct and indirect interaction between the public and nursing via the generation of nursing information and information dissemination, which influences the public's recognition, processing, and judgement of information (Ali et al., 2021;Gill & Baker, 2021;Girvin et al., 2016;Godsey et al., 2020;Maliheh et al., 2020).The public's recognition, processing and judgement of information play a leading role in the formation of the nursing image, which reflects the public's understanding and evaluation of nursing and is the core process in the formation of a nursing public image.

| Antecedents
Antecedents are factors that affect conceptual attributes.This study included three antecedents: factors related to nursing, factors related to the public, and special events.

| Nursing-related factors
Representative traditional nursing images mainly include handmaiden (Tzeng, 2006;Karanikola et al., 2011;Hadid & Khatib, 2015;van der Cingel & Brouwer, 2021;Lúanaigh, 2017), angels (Lúanaigh, 2017;Meiring & van Wyk, 2013) and sexy nurses (Lúanaigh, 2017;Kelly et al., 2012).The handmaiden embodies a male-dominated patriarchal hierarchical structure that requires nurses to perform nursing work according to the requirements of doctors.This is based on the stereotype that nurses are physicians' handmaidens (van der Cingel & Brouwer, 2021).The angel image emphasizes the caring qualities of the nurse, such as caring for the patient and being empathetic towards the patient's daily struggles (van der Cingel & Brouwer, 2021).Sexy nurses embody romanticism, which often results in their treatment as sexual objects as seen in many pornographic films (Kelly et al., 2012).The formation of these images is closely related to the historical, social, religious, cultural, political and geographical contexts in which nursing has evolved (Ali et al., 2021;Grinberg & Sela, 2022;Hadid & Khatib, 2015;Meiring & van Wyk, 2013;Mohsen et al., 2022;Squires et al., 2019;Varaei et al., 2012), and is the main source of the public image of nursing (Hoeve et al., 2014;Maliheh et al., 2020;Morris-Thompson et al., 2011).Although some traditional images of nurses have established positive images of nurses, such as the spirit of caring and dedication, most members of the public still view nursing as a lowstatus occupation and nurses as less skilled professionals (Hadid & Khatib, 2015).These negative views continue to affect the development of the contemporary nursing profession (van der Cingel & Brouwer, 2021).
These gender role stereotypes influence public perceptions and discourage men from pursuing nursing as a profession (Squires et al., 2019).In addition, male nurses still face many obstacles in their work, such as gender discrimination and negative patient attitudes (Sharma et al., 2022).Consequently, the turnover rate of male nurses is twice that of female nurses (Valizadeh et al., 2014).Sharma et al. (2022) pointed out the proportion of registered male nurses in various regions of the world, 9.1% in America, 10.7% in Britain, 2%-15% in Europe, 7.8% in Ireland, 4.9% in Japan and 1% in China.
These data indicate that the stereotype of a predominantly female profession which seriously limits the development of both the nursing profession and society.
The education level of nurses not only shapes the public image (Hadid & Khatib, 2015;Maliheh et al., 2020), but also affects the quality of health service delivery (Squires et al., 2019).The unequal level of entry requirements in nursing schools not only affects the public's perception of nursing but also nurses' perception of their own profession (Godsey et al., 2020;Rezaei-Adaryani et al., 2012).
Some British media have treated nursing as a profession with less rigorous educational training (Girvin et al., 2016).Nurse leaders and managers agree that higher levels of education will earn this profession more respect and trust (Sahakyan et al., 2020).Further, higher educational levels are associated with greater career development and have been shown to positively improve the overall image of nursing (Sahakyan et al., 2020).
Aspects such as nurses' uniforms, titles and occupational scope can also influence the public's perception of nursing (Auker, 2004;Daigle, 2018;Roshangar et al., 2021;Thomas et al., 2010;van der Cingel & Brouwer, 2021).For example, clothes, hairstyles and jewellery worn by the nurses can influence the patient-nurse interactions and therapeutic relationships (Thomas et al., 2010).Additionally, in a healthcare setting, when patients cannot distinguish nurses' uniforms from those of other assistant staff or when the name tag, title and qualifications are not clear, they are likely to perceive the nurse's role negatively (Godsey et al., 2020).In Iran, the terms 'Parastar' and 'nurse' are used interchangeably to designate any person responsible for providing any kind of care in a hospital or home (nursing assistant, person in charge of home care for children or older adults) (López-Verdugo et al., 2021;Roshangar et al., 2021).Additionally, nurses often perform jobs outside their scope of practice, including the roles of physicians, laboratory technicians and pharmacists (Ndirangu et al., 2021;Roshangar et al., 2021).This scenario conveys inconsistent or incorrect messages that confuse and obscure the public perception, leading to an incorrect image of nursing (Godsey et al., 2020;López-Verdugo et al., 2021).
The professional behaviour of the nurse, including providing care to the patient, determines the patient's experience of nursing care (Wocial et al., 2014), which also affects the nursing image (Emeghebo, 2006).In any profession, the negative behaviour or performance of some members can affect their perception of the entire profession (Glerean et al., 2019;Godsey et al., 2020;Morris-Thompson et al., 2011;Valizadeh et al., 2014).Common examples include arguing in the workplace (Godsey et al., 2020), laziness at work (Appiah et al., 2020), inappropriate use of mobile phones during working hours and other similar unprofessional behaviour (Appiah et al., 2020), and replies like 'ask your physician' and 'I don't know' when a patient asks a nurse about their illness.Such actions lead patients to perceive the nurse as incompetent, and damage the public image of nursing (Valizadeh et al., 2014).
| 11 of 17 Nursing is the largest healthcare profession, however, nurses rarely participate in public discussions on the impact and value of their role in healthcare (Maliheh et al., 2020).In addition, nurses do not invest sufficient energy in creating and maintaining a positive professional image (Hoeve et al., 2014).Disunity among nurses has also contributes to a decline in their public image (Rezaei-Adaryani et al., 2012).

| Public-related factors
Many studies have suggested that the behaviour and language of professional colleagues as internal organizational public, such as hospital administrators and physicians, are most likely to affect the public image of care (Ali et al., 2021;Emeghebo, 2006;Foà et al., 2021;Girvin et al., 2016;Godsey et al., 2020;Valizadeh et al., 2014).A positive image of nursing by other health professionals promotes the better integration of nurses into multidisciplinary teams (Foà et al., 2021).In contrast, when physicians use demeaning comments in front of patients or other professionals or nurses, the image of nursing is damaged to some extent (Ali et al., 2021;Emeghebo, 2006;Girvin et al., 2016;Godsey et al., 2020;Valizadeh et al., 2014).In addition, the communication patterns of members of different professions can directly affect patient care and professional image (Apaydin Cirik et al., 2022;Ndirangu et al., 2021).Support from family members or friends and information about the nursing profession may influence young people's decisions to pursue nursing as a profession (Girvin et al., 2016;Glerean et al., 2017;Glerean et al., 2019;Mohsen et al., 2022;Morris-Thompson et al., 2011;Varaei et al., 2012).
When a nurse is a relative, they can creat a positive impression of nursing care for family members (Varaei et al., 2012).Interactions between caregivers, patients and families can enhance or improve the professional image of nursing (Hadid & Khatib, 2015;Rubbi et al., 2017).In particular, patients who receive care regular care have more opportunities to learn about other aspects of care and thus have a positive perception of care (Foà et al., 2021).
Mass media is one of the most important variables affecting the public image of nursing.The information conveyed by the media shapes people's attitudes and views about nursing (Auker, 2004;Cabaniss, 2011;Donelan et al., 2008;Foà et al., 2021;Glerean et al., 2017;Grinberg & Sela, 2022;Maliheh et al., 2020;Morris-Thompson et al., 2011;Rezaei-Adaryani et al., 2012;Rubbi et al., 2017;Şahan et al., 2021;Ward, 2006).This is particularly true in the absence of personal experience with nurses and/or healthcare providers.In such cases, the public's perception of care is largely derived from information obtained from television, novels, movies and the Internet (Price & McGillis Hall, 2014).When the media actively reports on the performance of care in emergencies, such as the fight against COVID-19, it gains public praise (Cao et al., 2022).
However, some media outlets ignore the contribution of nursing care to healthcare or present it unrealistically or unfavourably (Morris-Thompson et al., 2011;Varaei et al., 2012;Lúanaigh, 2017).
The media continues to reinforce stereotypes of nurses, such as angels, doctors' maids, battleaxes and sexy nurses (Hoeve et al., 2014;Karanikola et al., 2011;Kelly et al., 2012).In addition, negative events during nurses' service delivery are often highlighted in social media and newspapers (Girvin et al., 2016;McGillis Hall & Kashin, 2016), providing nurses with a professional image of failure and incompetence (Rodríguez-Pérez et al., 2022).Inaccurate and misleading portrayals of nurses and the nursing profession in the media not only damage the public perception of nursing, but also seriously hinder the development of the nursing profession (Afshar et al., 2020;Gill & Baker, 2021;Godsey et al., 2020).
Individual knowledge levels play a role in the perception of nursing image (Cabaniss, 2011;Varaei et al., 2012).As reported by RoshanOAr et al. ( 2021), the ambiguous image of nurses among the Iranian public is due to their lack of awareness and knowledge of their nursing roles, responsibilities, and capabilities.Morris (2010) found that the public seemed to lack an understanding of the reality of nursing, including remuneration, the nature of nursing work, professional autonomy and the opportunities for clinical career promotion.
Personal values and preferences also affect every image and judgement in people's minds (Cabaniss, 2011;Maliheh et al., 2020;Valiee et al., 2020).In their analysis of nursing images, Kalisch give nurses a unified identity that includes being hardworking, lowpaid, conscientious, passive, oppressed, caring and female (Morris-Thompson et al., 2011).
Multiple studies have demonstrated a link between the experiences of patients or family members receiving care and their image of nursing care (Donelan et al., 2008;Girvin et al., 2016;Godsey et al., 2020;Hadid & Khatib, 2015;Maliheh et al., 2020;Meiring & van Wyk, 2013;Ward, 2006).In Hadid and Khatib's (2015) study, respondents who received nursing care were more familiar with the job responsibilities of nurses and reported a better image of nursing.Girvin et al. (2016) revealed that respondents who received nursing services from nurse specialists expressed a more positive impression of nursing professionals.Nurses' attitudes towards patients (Squires et al., 2019) and the frequency with which patients and their families receive care (Hadid & Khatib, 2015;Woldasemayat et al., 2022;Godsey et al., 2020) affect the public's perception of the nursing profession.

| Special events
When nursing staff face major emergencies such as SARS, the Ebola virus, COVID-19, the Indian tsunami and the Wenchuan earthquake, they make important contributions to alleviating human suffering (Godsey et al., 2020;McGillis Hall & Kashin, 2016;Rezaei-Adaryani et al., 2012;Tzeng, 2006).These events give the public an opportunity to learn more about the efforts and capabilities of the nurses (Foà et al., 2021;Roshangar et al., 2021).Nurses are greatly respected by the public (Cao et al., 2022;Donelan et al., 2008;Şahan et al., 2021;van der Cingel & Brouwer, 2021;Zhang et al., 2021), have a positive impact on the public image of the nursing profession, and enhance the professional identity of nursing (Apaydin Cirik et al., 2022).

| Consequences
This study included outcomes related to nursing and to the public.
Numerous studies have found that the public image of nursing is positively correlated with the quality of care (López-Verdugo et al., 2021;Valiee et al., 2020).Indeed, nurses have often reported that public criticism affects their ability to focus on work, which is a possible cause for mistakes.Many studies have demonstrated that a poor public image has also resulted in many secondary school students shunning away from choosing nursing as their major (Foà et al., 2021;Hadid & Khatib, 2015;Morris-Thompson et al., 2011;Rubbi et al., 2017) and increased nurse turnover rates (Apaydin Cirik et al., 2022;Elmorshedy et al., 2020;Maliheh et al., 2020;Takase et al., 2006).This indicates that negative stereotypes about nursing affect the number of people willing to join the profession and service delivery by nurses (Auker, 2004;Hadid & Khatib, 2015;Hoeve et al., 2014;Karanikola et al., 2011;Meiring & van Wyk, 2013;Mohsen et al., 2022;Price & McGillis Hall, 2014).However, gender stereotypes discourage men from joining the nursing profession (Glerean et al., 2017;Roshangar et al., 2021;Weaver et al., 2014).In addition, studies have demonstrated that a poor professional image increases nurses' dissatisfaction at work (Grinberg & Sela, 2022;Valizadeh et al., 2014;Varaei et al., 2012), their intention to quit the profession, and the dropout rate of nursing students (Apaydin Cirik et al., 2022).
A few studies believe that the social image of nursing does not match the real situation of the nursing profession, resulting in conflicts in interprofessional cooperation (Godsey et al., 2020;Rezaei-Adaryani et al., 2012).In addition, it affects resource allocation and decision-making and hinders the expansion (Grinberg & Sela, 2022;Kalisch et al., 2007) and development of the profession (Sahakyan et al., 2020;van der Cingel & Brouwer, 2021;Zhang et al., 2021).

| Consequences related to the public
A positive public image of nursing reflects high-quality care and can positively affect patient health (Cabaniss, 2011;Varaei et al., 2012).
However, the poor public image of nursing discourages teamwork and fosters staff competition, leading to adverse patient outcomes (Godsey et al., 2020;Woldasemayat et al., 2022).
The public image of nursing is one of the most important factors affecting patient satisfaction (Rezaei-Adaryani et al., 2012;Valiee et al., 2020).Nurses' professional behaviour and good communication can enhance patients' comfort and satisfaction (Maliheh et al., 2020).Woldasemavat et al. (2022) showed that when nursing care satisfaction increased by one point, patients' perceptions of their occupation increased by 1.769 times.
Several studies have found that the public image of nursing can directly affect the public's trust in and respect for the nursing profession (Gill & Baker, 2021;López-Verdugo et al., 2021;Rezaei-Adaryani et al., 2012).Recent studies have found that the COVID-19 pandemic has made the public more aware of the nursing profession and changed their perceptions of nursing.In addition, the pandemic increased the trust the public has in nursing (Şahan et al., 2021).
| 13 of 17 As the largest community in the healthcare system, nurses plays an important role in ensuring the proper functioning of health services (Morris-Thompson et al., 2011).Opposing views of the public towards the nursing profession hinders nurses from meeting the health needs of society (Roshangar et al., 2021), indirectly affecting the overall level of national health due to a shortage of nursing staff (Lúanaigh, 2017).

| Surrogate and related term
Surrogate terms can be used interchangeably to express concepts.
Related concepts are terms with common attributes and different characteristics from the original concepts (Rodgers & Knafl, 2000).
The surrogate terms in this study included the social image of nursing (López-Verdugo et al., 2021;Lusk, 2000) and nursing group images (Auker, 2004).Related concepts of public nursing image include

| DISCUSS ION
This study clarified the attributes, antecedents, and consequences of the public image of nursing through concept analysis.

| Analysis of nursing attributes
We identified nursing (nursing as the collective object), public (public as the collective object) and information (the medium of interaction between the collective subject and collective object) as attributes associated with the formation of a public image of nursing.Nursing elements consist of both intrinsic and extrinsic factors.Two scholars conducted conceptual analyses of nursing images.Ward (2006) believes that care, attitudes, knowledge, behaviour, autonomy, and They postulated that the mass media could be both public view and a medium tool from different aspects.However, this study argues that simply viewing mass media as a tool for information dissemination does not reveal the impact of media images on the nursing profession.As a result, the focus should be on the description of the care presented by the media, which is fabricated by media personnel or media organizations and represents their view of care (Squires et al., 2019).Media image is a processed and socialised product that reflects the demand for politics and power in contemporary society (Girvin et al., 2016).Media images of nursing and public opinion have a lasting and profound impact on the public, as they can change the public's perception of nursing.This study considers mass media as a public category.
The public constructs a subjective perception of nursing, recognising it as a subject to appraise and shape their understanding

| Analysis of information attributes
As an attribute of the nursing public image, information was analysed from the objective relationship between nursing and the public.Information is an essential element in image generation, as a medium for nursing and public interaction.Public perception of information is a process in which the public actively identifies, processes, and judges the transmitted information.Many studies have shown that the perception of the public regarding nursing care does not coincide with the practice of care (Foà et al., 2021;Hadid & Khatib, 2015;Hoeve et al., 2014;López-Verdugo et al., 2021).
This may be because of the authenticity (Foà et al., 2021) and completeness of the information (Girvin et al., 2016).Inaccurate representations in the media can lead to negative feelings towards the services offered by nurses to patients, other professionals, and society (Gill & Baker, 2021).Limited contact with nursing has contributes to the public's partial understanding of nursing (Godsey et al., 2020).The more nursing services the public receives, the higher the public knowledge about nursing, and the more positive the public perception of the nursing profession (Hadid & Khatib, 2015).

| Analysis of antecedents and consequences
We selected two attributes of nursing (nursing as the collective object) and public (public as the collective subject), to determine the factors influencing the public image of the nursing profession.In recent decades, nursing practices have contributed to the improvement of social healthcare during various disaster events.This has increased the visibility and awareness of the nursing profession in several public events, such as health disasters.Additionally, the recent COVID-19 pandemic has affected the public image of nursing.
Poor public image of nursing results in negative outcomes during the provision of nursing services.
ginning of the twenty-first century.The workplace, nature of work, role, and scope of nursing are now considerably enriched and broad, resulting in a diverse and complex nursing profession.As such, there is a need to update the characteristics of nursing.An Iranian scholar Rezaei-Adaryani et al. (2012) developed a schematic model for understanding the nursing image by conducting an evolutionary concept analysis of antecedents, attributes and consequences.The attributes of the nursing image encompass four domains: the public's perception of nursing image, self-image of nursing, nurses' perception of the public image, and nursing image portrayed in the media.Furthermore, the concept of nursing image is multidimensional, all-inclusive, paradoxical, dynamic and complex.However, existing study only indicated the categories of nursing image and did not analyse the components of the nursing public image.Consequently, | 3 of 17 DUAN et al.

F
Results of a thematic analysis with included citations (n = 54).
state that a positive image of nursing lies in the public's belief that nurses are qualified.Communication skills are especially important in effective nurse-patient interactions, and proper communication and respect positively influence patients' trust in nurses(Rodríguez- Pérez et al., 2022;Valiee et al., 2020).Interpersonal skills are often the standard for judging the quality of the nursing service(Price & McGillis Hall, 2014).

a
certain attitude of the public towards nursing and affects their overall assessment of nursing.The emotional reactions of the public towards nursing depend on the public's level of cognition regarding the profession.When the public has an inaccurate view of the nursing, the profession is easily misrepresented(Rodríguez-Pérez et al., 2022).Mass media and the experience of the public when interacting with nurses are two important aspects that shape the public's feelings towards nursing.For example, negative images about nursing portrayed by mass media are more likely elicit negative attitudes towards nursing(McGillis Hall & Kashin, 2016;Şahan et al., 2021) and influence the public to view many aspects of nursing negatively(Meiring & van Wyk, 2013).Media praises in nursing feats is likely to influence viewers' positive perceptions of nursing(Cao et al., 2022).Squires et al. (2019) found a positive relationship between the nurses' attitudes towards caring for patients and their perceptions of care.Behavioural intention refers to the intention of the public to use care services, and it plays a crucial role in determining the behaviour that the public adopts regarding to nursing.Behavioural intentions are partly derived from emotional reactions(Thomas et al., 2010).Patients' feelings about nurses can influence their behaviours, such as their willingness to provide personal information during nursing evaluations and their willingness to receive educational and therapeutic interventions(Daigle, 2018;Thomas et al., 2010).Positive emotions may result in individuals exhibiting positive inclinations towards certain behaviours(Donelan et al. (2007) pointed out that the basic values acquired by all people in the process of socialisation affect the cognitive process of individuals, resulting in ingrained distorted knowledge and beliefs, including views on professional groups.People are unaware of the nurses' professional qualifications, expertise, and education.Instead, they nursing and professional nursing images.The related concepts had content similar to the public image of nursing.Rezaei-Adaryani et al. (2012) stated that the nursing images includes the public image of nursing and described a broader conceptual category.The nursing professional image is derived from the perceived population, including nursing and non-nursing staff.Therefore, the concept of nursing image is based on the impressions and perceptions of nursing.The core of the different concept names depends on the different populations that forms their perception.
nurse uniforms are the elements of the nursing image.Therefore, the author focuses on explaining public image of nursing from the one-dimensional perspective of nursing connotations.The six elements of nursing image proposed by Ward frequently appear in literatures included in this study.These elements summarise the characteristics and attributes of nursing.However, with the multidirectional development of the nursing profession, these elements can no longer fully reflect the connotations of nursing.Therefore, this study classified the elements of nursing (objects) into professionalism, knowledge, and skills.Professionalism is the core element of nursing attributes and embodies the ideals, beliefs, value pursuits and moral norms shared by the entire nursing community.In addition to professionalism, nursing specialisation is the focus of nursing work(Afshar et al., 2020).This specialisation is based on the professional knowledge and skills of the nursing staff, which are also important in cultivating professionalism(Afshar et al., 2020).These three elements are interrelated and collectively reflect the intrinsic nursing characteristics.These characteristics are expressed through the specific behaviour, language and appearance of members of the profession when they are active in the field of nursing.Intrinsic and extrinsic factors are organically unified and collectively constitute the nursing dimensions.Many studies have explored the perceptions and attitudes of nursing students towards the nursing profession.In these studies, nursing students were treated as part of the public population.This study concluded that the professional identity of nursing students and their performance, such as their comments on social media related to or unrelated to the profession, influenced their people's perceptions of nurses(De gagne et al., 2019).Therefore, as a nursing community subgroup, they are also an important part of the image of nursing.4.1.2| Analysis of public attributesIn their concept analysis,Rezaei-Adaryani et al. (2012) proposed that nursing public image is a dimension of nursing image.However, this concept has not yet been analysed or explained further.In summary, we summarized the attributes of the public (subject), including public categories and public perceptions.In previous studies, the classification of public categories varied.The various public categories were affected by individual experiences, values and cognitive levels because the studies reported different understandings of nursing images.Thus, from the perspective of public relations, communication and the above factors, a reasonable division was developed in this study based on close interactions between the public and nurses.Rezaei-Adaryani et al. (2012) considered media images as another dimension of nursing images.
through a synthesis of objective facts, cognitive assessment, and emotional components.This subjective reality is not a mirror reflection of objective reality but a comprehensive judgement made by the selective processing of objective things based on one's values.In addition, this subjective feature indicates that the quality of the experience of the public, judgement and evaluation of nursing are key factors in forming a positive or negative public image of nursing.In addition, public perception should consider individual and group factors.Individual factors imply that the attitudes and views of different individuals towards the same thing are always different because of differences in individual cognition, emotion, will and other factors.Individual perceptions are often susceptible to the influence of group perceptions, resulting in herd conformity.